On June 29, 2022, a 23-year-old young woman with a BMI of 18.2kg/m2 was admitted to our hospital because of EPs found more than half a year ago. The patient lacked exercise at ordinary times and denied previous history of surgery as well as chronic diseases in the past. The examination of ovarian reserve function in another hospital found that AMH was low (less than 1ng/ml), indicating primary ovarian insufficiency. She had regular menstruation and had never been pregnant. No special family disease history.
More than half a year ago, EPs was seen by the uterine ultrasound examination in this patient, whose vaginal discharge, meanwhile, were positive for mycoplasma, bacteria and fungi. The vaginal discharge was performed again after treatment with "nifuratel nystatin vaginal soft capsules and doxycycline hyclate tablets", and was negative for mycoplasma and bacteria but still positive for fungi. The patient was then treated with "clotrimazole tablet" for 4 times. However, her subsequent vaginal discharge still showed positive for fungus. Luckily, the fungus finally turned negative after receiving the treatment of "fluconazole tablets". Therefore, the patient was admitted to the hospital for hysteroscopic surgery.
The patient's routine hysical examination and gynecological examination at admission was negative. After admission, blood routine, coagulation function, liver and kidney function, preoperative evaluation of infectious diseases, electrocardiogram, and chest X-ray were performed and no obvious abnormalities were found. Given the patient had fertility requirements, she met the inclusion criteria of a clinical study being conducted in our hospital (clinical trial numbers: ChiCTR2200058712). After signing informed consent, the patient was recruited into the study (ethical review approval number: 20210620213357026-FS01). In addition, the patient required tubal hydrotubation during the operation because she failed in trying to conceive for more than half a year.
The vital signs of the patient were stable before the operation (Fig. 1). During the operation, a catheter was inserted into the uterine cavity, and 20 mL of physiological saline was injected without obvious resistance, indicating that the fallopian tube was unobstructed. Under hysteroscopy, there were five polyps in uterine cavity. The largest one was about 0.8*0.5cm, while the smallest one was about 0.3*0.3cm. All the polyps in uterine cavity were cut to the base by the rotating movements of the inner blade, and the abraded fragments were aspirated and sent for pathological examination. The operation was successfully completed in about 8 minutes and she was sent to the ward for observation after surgery.
About 3 hours after surgery, the patient developed mild lower abdominal pain with elevated body temperature (up to 38.7°C)、heart rate (up to 92–120 bpm)、respiratory rate (up to 27 bpm), and hypotension (about 72–83/35-54mmHg) (Fig. 1). Laboratory examination showed that white blood cells decreased to 3.18×109/L (up to 22.39×109/L later), the proportion of neutrophil increased (up to 98.5%), and the index of infection increased significantly, including hypersensitive C-reactive protein (up to 45.13mg/l), procalcitonin (up to 42ng/ml), interleukin (up to 3120pg/ml) (Fig. 2). Combined with the clinical manifestations and laboratory examination, the patient was considered to have postoperative septic shock. Then she was transferred to ICU for further treatment. ICU physicians gave piperacillin tazobactam combined with tinidazole for anti-infection, epinephrine for vasoconstriction, fluid replacement, supplementation of albumin, etc. After treatment, the patient's condition was gradually relieved, which was characterized by stable recovery of vital signs, gradual decline of white blood cells and infection indicators. At this moment, the blood culture result was negative. So, she was returned to Gynecology ward on the 3rd day after operation. After antibiotic therapy for 10 days, abdominal ultrasound was performed and showed a small amount of effusion. The results of white blood cells and various infection indicators were normal before discharged. Ultrasound imaging and hysteroscopic view were shown in Fig. 3. Histopathologic examination of EPs was shown in Fig. 4.